Infertility

t is not well understood how endometriosis can cause infertility, in the majority of cases.

It is easy to understand, when endometriosis is severe, because it causes anatomical damage to the reproductive organs. Significant adhesions may hinder the function of the tube. In cases of blocked tubes (hydrosalpinges), the sperm can not meet the egg to fertilize it.

Other theories have been suggested:

• Bad quality of the egg because of toxic actions of the endometriosis
• Various chemicals can impede the movement of the tube and the propulsion of the fertilized egg towards the uterus
• Inflammatory factors activate the white blood cells to attack the sperm
• The ovarian wall may thicken, subsequent to the endometriosis related inflammation, and the egg is trapped inside the ovary.

Many studies have shown that operative laparoscopy in women with endometriosis stage I and II (AFS) improves the chances of spontaneous conception, when the endometriotic implants are destroyed and the adhesions removed.

In cases with ovarian chocolate cysts (endometriomas), surgery improves pregnancy rates. The surgeon must be careful, to remove as little as possible normal healthy ovarian tissue, in order to preserve the ovarian reserves.

In cases of deep infiltrating endometriosis, there is no evidence that surgery increases the chances of spontaneous conception.

It is important not to delay a surgical intervention.

There is no evidence, that medical adjuvant treatment prior or after surgery, increases the chances of conception in infertile women with endometriosis.

In infertile women with endometriosis assisted reproduction increases the chances of conception. Medically assisted reproduction includes in vitro fertilization IVF and intrauterine insemination IUI.

The partner’s sperm is prepared with Percoll or swim up. These techniques select the best sperm. Then, the sperm is placed into the uterus via a fine catheter, during ovulation.

The cycle is monitored with transvaginal ultrasound scans and hormonal measurements. Gonadotrophins can also be used to increased the number of oocytes. When the follicles reach the size of 17mm or more, the oocytes are mature and the insemination takes place.

In women with minimal or mild endometriosis, intrauterine insemination with light stimulation of the ovaries with gonadotrophins, significantly improves the pregnancy rate.

Some studies have shown that after surgery, intrauterine insemination with light stimulation of the ovaries with gonadotrophins, significantly improves the pregnancy rate. This is also an option for women with a chocolate cyst or more advanced stages of the disease. However, in these the effectiveness of the technique is not well documented.

The pregnancy rates are higher after light stimulation of the ovaries compared to a natural cycle.

The administration of FSH (Gonal, Puregon, Follistim, Merional, Menopur, Altermon) is more effective than clomiphene citrate (Clomid, Serpaphar).

If you have not conceived after 3-4 inseminations, the chances of success are reduced and it is better to proceed to IVF without waisting time.

Intrauterine insemination is not option in the following cases:

• Blocked tubes
• Severe male factor infertility
• When other treatments have failed

In these cases is better to proceed to IVF.

A significant proportion of women with moderate to severe endometriosis will achieve a pregnancy only following IVF.

Women undergo controlled ovarian stimulation, to produce 8-10 eggs. The cycle is monitored with scans and hormonal measurements. The oocyte pick up is performed transvaginally, under ultrasound control, with light sedation.

The eggs are fertilized in a test tube (conventional IVF) or a sperm is injected into the egg, in cases of sperm problems (ICSI).

Egg collection is covered with prophylactic antibiotics, especially in women with chocolate cysts.

IVF seriously helps women with endometriosis to overcome their infertility and become pregnant.

Endometriosis recurrence is not more common after controlled ovarian stimulation.

There is some evidence that, administration of GnRh analogues for 3-6 months prior to IVF, increases the chances of pregnancy, in women with endometriosis.

There is no strong proof that, surgical treatment prior to IVF increases the chances of pregnancy. The opposite is also true, that an operation will not reduce the chances of pregnancy. Your doctor might advise you, that you are better off having IVF after surgical treatment for endometriosis, in cases of pain or large cysts, when it is difficult to collect the eggs.

Removing deep infiltrating endometriosis prior to IVF, is not associated with higher success rates.

It was widely believed for a long period of time, that the success rate of IVF in women with endometriosis was 30% lower, than those with tubal infertility.

Women with endometriosis respond less to the stimulation of the ovaries, they produce less oocytes and less embryos, than women with tubal infertility.

However, analysis of mega data of national IVF registries of many states, has shown that the results of IVF in women with endometriosis are better, than those with tubal disease. Hundreds of thousands of cycles were analyzed and the statistical power of the results is beyond doubt.

From my personal experience of 25 years as an IVF doctor, I have witnessed excellent IVF results in women with endometriosis.

Young women with stage 4 endometriosis, even if they do not produce many eggs, have excellent pregnancy rate.

As women get older, the influence of endometriosis is more marked.

Therefore the sooner a woman with endometriosis undergoes IVF, the higher the chances of a pregnancy.